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Dr. Mike Munro
14500 S. Outer 40, Suite 100
Town and Country, MO 63017
314-485-8058
Date
First Name
Sex Male Female
Married/Civil Union:
Home #
Address
City
Emergency Contact
Patient Information:
SSN
Middle Name
Height
Spouse Name
Cell #
State
Emergency Relation
Birthday
Last Name
Weight
# of Children
Work #
Zip
Emergency Phone
Patient Symptoms:
What is the purpose of your visit?
Date of scheduled appointment
How long have you had this condition?
What is the reason for this visit?
When did this condition begin?
What caused this condition?
Where is the discomfort? Choose all that apply.
Head: Front of head Back of head Right side of head Left side of head
Neck: Front of neck Back of neck Right side of neck Left side of neck
Back: Right mid back Left mid back Central mid back Right low back Left low back Central low back
Trunk: Abdomen Chest Front of ribs Back of ribs Right side of ribs Left side of ribs
Upper Extremity: Front of right upper extremity Rear of right upper extremity Front of left lower extremity Rear of left lower extremity
Front of right shoulder Rear of right shoulder Front of left shoulder Rear of left shoulder
Front of right upper arm Rear of right upper arm Front of left upper arm Rear of left upper arm
Front of right elbow Rear of right elbow Front of left elbow Rear of left elbow
Front of right wrist Rear of right wrist Front of left wrist Rear of left wrist
Front of right hand Rear of right hand Front of left hand Rear of left hand
Lower Extremity Front of right lower extremity Rear of right lower extremity Front of left lower extremity Rear of left lower extremity
Front of right hip Rear of right hip Front of left hip Rear of left hip
Front of right thigh Rear of right thigh Front of left thigh Rear of left thigh
Front of right knee Rear of right knee Front of left knee Rear of left knee
Front of right leg Rear of right leg Front of left leg Rear of left leg
Front of right ankle Rear of right ankle Front of left ankle Rear of left ankle
Top of right foot Bottom of right foot Right side of right foot Left side of right foot
Top of left foot Bottom of left foot Right side of left foot Left side of left foot
OTHER
Does the discomfort radiate/travel? Yes No
Where does the pain radiate to? Choose all that apply; choose non-radiating if none apply.
Non-radiating
Front of left chest Front of right chest Front of left abdomen/groin Front of right abdomen/groin
Front of left thigh Front of left lower leg Radiating to top of left foot Front of left shoulder
Front of left upper arm Front of left lower arm Front of left hand Front of left face
Front of right thigh Front of right lower leg Radiating to top of right foot Front of right shoulder
Front of right upper arm Front of right lower arm Front of right hand Front of right face
Back of left thigh Back of left lower leg Bottom of left foot Back of left shoulder
Back of left upper arm Back of left lower arm Back of left hand Back of left side of head
Back of right thigh Back of right lower leg Bottom of right foot Back of right shoulder
Back of right upper arm Back of right lower arm Back of right hand Back of right side of head
Describe the quality of the discomfort. Choose all that apply.
Aching Annoying Burning Deep Diffuse Dull
Heavy Intolerable Pulling Sharp Shock-like Shooting
Stabbing Stiffness Throbbing Tightness Tingling OTHER
Complaint Information:
Onset of discomfort: Gradual Insidious Recent Spontaneous Sudden Traumatic Unknown
Intensity of discomfort: Mild Mild to moderate Moderate Moderate to severe Severe
Severity of discomfort: 1 2 3 4 5 6 7 8 9 10
Frequency of discomfort: Constant Frequent Intermittent On and off Random Recurring
How has severity of the complaint changed since the onset? Improved Stayed the same Worsened
What activity is most significantly affected by this discomfort?
What improves this condition? Choose all that apply.
Chiropractic adjustment Cold packs Exercise Heat packs Massage
Nothing OTC medications Physical therapy Prescription medication Re-direct attention
Rest Stretching Work OTHER
What treatment have you received for this condition up to now?
None Acupuncture Chiropractic care Craniosacral therapy Homeopathic medicine
Hypnosis Injection therapy Medical care Naturopathic medicine Nutritional supplements
Occupational therapy Osteopathic medicine OTC medications Physical therapy Prescribed medications
Psychotherapy Reiki Surgery OTHER
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)? Yes No Unsure
Have you ever had any previous episodes of this condition? Yes No
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Bending over Caring for family Climbing stairs Concentrating Dressing myself
Driving a car Exercising Getting in/out of car Getting to sleep Grocery shopping
Household chores Lifting objects Looking over shoulder Love life Lying down
Reaching overhead Rising out of chair or bed Showering or bathing Sitting Standing
Staying asleep Using a computer Walking Yardwork
Do you have an additional complaint? Yes No
Complaint #1 Information (2):
Musculoskeletal - Other than the musculoskeletal complaints you mentioned already, do you have or have you ever had:
No additional musculoskeletal complaints Osteoporosis Arthritis
Scoliosis Joint or muscle pains/stiffness Cramping
Swelling, redness deformity of joint(s) Fractures Implants, plates, pins or screws
Neck pain Back problems Hip disorders
Knee injuries Foot/ankle pain Shoulder problems
Elbow/wrist pain Poor posture Gout
Neurological - Other than the neurological complaints you mentioned already, do you have or have you ever had:
No additional neurological complaints Anxiety and/or panic Depression
Memory issues Sleeping issues Headache
Dizziness Weak muscles Pins and needles
Numbness Loss of smell or taste Temporary loss of vision, smell or hearing
Difficulty concentrating Stroke Epilepsy or seizures
Head, Eyes, Ears, Nose and Throat - Do you have or have you ever had:
No complaints Headaches or migraines Eye or vision problems Eyeglasses or contact lenses
Eye surgery Cataracts Glaucoma Nose congestion or sinus trouble
Ear or hearing problems Dental problems Gum problems TMJ problems
Sore throat Postnasal drip Swollen lymph nodes OTHER
Cardiovascular - Do you have or have you ever had:
No cardiovascular complaints Chest pain or tightness Palpitations Swollen legs or feet
High blood pressure Low blood pressure High cholesterol or triglycerides Heart attack
Heart murmur Congenital heart defects Rheumatic fever Leg pain upon walking
Blood clots Varicose veins Dizziness Excessive bruising
Coronary artery disease OTHER
Respiratory - Do you have or have you ever had:
No respiratory complaints Persistent cough Wheezing Shortness of breath
Snoring issues Tuberculosis Pneumonia Blood in sputum
Asthma Apnea Emphysema Hay fever
OTHER
Gastrointestinal - Do you have or have you ever had:
No gastrointestinal complaints Abdominal pain Nausea or vomiting Bloating
Heartburn Ulcer Difficulty swallowing Jaundice
Liver disease Gallbladder problems Pancreatitis Change in bowel habits
Black or bloody stool Colon cancer or colon polyps Hemorrhoids Food sensitivities
Constipation Severe diarrhea Irritable Bowel Syndrome Crohn's disease
Gastric reflux Collitis OTHER
Genitourinary - Do you have or have you ever had:
No genitourinary complaints Painful or frequent urination Blood in urine Kidney stones
Urinary infections Sexual dysfunction Incontinence OTHER
Review of Systems:
Endocrine - Do you have or have you ever had:
No endocrine complaints Feeling hot or cold all the time Thyroid problems Diabetes
Increase urination Excessive thirst Hyperthyroidism Hyperparathyroidism
Testosterone deficiency Cushing's syndrome Steroid treatments OTHER
Dermatological and Bleeding - Do you have or have you ever had:
No skin or bleeding complaints Skin trouble or rashes Flushing Change in hair or nails
Excessive acne Eczema Psoriasis Skin cancer
Skin pigmentation issues Blood in stool Easy bruising Gum bleeding
OTHER
Review of Systems (2):
Are you pregnant? Yes No
Are you nursing? Yes No
Do you perform a regular self breast examination? Yes No
Do you take oral contraceptives? Yes No
Date of last PAP/pelvic exam?
For Women Only:
Are you taking birth control? Yes No
Do you experience painful periods? Yes No
Date of last mammogram?
Do you take HRT? Yes No
Do you have irregular cycles? Yes No
Do you have breast implants? Yes No
Date of Last Menstrual Period?
List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Yes, surgical history
No surgical history
Abdominal aortic aneurysm repair
Appendectomy
Biopsy
Bunionectomy
Cardiac bypass
Cardiac valve replacement
Carpal tunnel - left
Carpal tunnel - right
Cataract - left
Cataract - right
C-section
Cosmetic - face lift
Cosmetic - nose
Cosmetic - breast reduction or enlargement
Cosmetic - tummy tuck
Cosmetic - other
Ear tubes
Gall bladder removed
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Gastric bypass
Hysterectomy - complete
Hysterectomy - partial
Knee - left
Knee - right
Lasik
Mastectomy
Shoulder - left
Shoulder - right
Thyroidectomy
Tonsils
Tonsils & adenoids
Wisdom teeth
Discectomy level
Implants
Ganglion cyst
Spinal fusion
Transplant
OTHER
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred.
Yes, past illnesses No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)
Number of children Number of pregnancies Number of deliveries
AIDS/HIV
Alcoholism
Alzheimer's
Anemia
Anorexia
Arthritis
Asthma
Bleeding disorders
Breast lump
Bronchitis
Bulimia
Cancer
Chemical dependency
Congenital anomaly
Depression
Diabetes
Emphysema
Age
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Age
Age
Age
Age
Age
Age
Age
Age
Age
Explain
Explain
Past, Family and Social History:
Epilepsy
Extremity issues
Fracture
Heart disease
Hepatitis
Hereditary disorder
Hernia
Herniated disc
High blood pressure
High cholesterol
Hospitalization
Kidney disease
Liver disease
Migraine headaches
Miscarriage
Multiple sclerosis
Natural labor
Neuromuscular issues
Osteoarthritis
Osteoporosis
Pacemaker
Parkinson's disease
Pinched nerve
Pneumonia
Polio
Previous chiropractic care
Prostate problems
Psychiatric care
Rheumatoid arthritis
Stroke
Suicide attempt
Thyroid problems
Trauma/injury
Tumor
Ulcers
Vaginal infection
Venereal disease
OTHER
Age
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Age
Age
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Age
Age
Age
Age
Age
Age
Age
Explain
Explain
Explain
Explain
Explain
Explain
Past, Family and Social History (2):
List any past history of accidents or trauma. Choose all that apply.
No previous trauma reported No new trauma reported since initial intake Single automobile accident
Multiple automobile accidents Slip and fall Multiple slip and falls
Single motorcycle accident Multiple motorcycles accident Single boating accident
Multiple boating accidents Resulting in fracture(s) Resulting in permanent injury or disability
Resulting in hospitalization(s) Resulting in no significant injury or loss Resulting in sprains/strains
Resulting in loss of consciousness Suicide (including attempts) OTHER
Are you presently taking any medication? Yes No
Which of the following medications are you presently taking? Choose all that apply.
Over-the-counter Prescription Antidepressant Muscle relaxer
Anti-inflammatory (NSAID) Steroidal Anti-inflammatory Antacid Anti-viral
Aspirin Chemotherapy Codeine Hallucinogenic
Marijuana Mood elevator Sleeping pill Stimulant
Tranquilizer OTHER
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
No family history of diabetes, cancer, hypertension and progressive neurological disorders.
Not applicable, patient was adopted No change in family health history Unknown
AIDS/HIV Alcoholism Alzheimer's Anemia Anorexia
Arthritis Asthma Bleeding disorders Breast lump Bronchitis
Bulimia Cancer Chemical dependency Congenital anomaly Depression
Diabetes Emphysema Epilepsy Extremity issues Fracture
Heart disease Hepatitis Hereditary disorder Hernia Herniated disc
High blood pressure High cholesterol Hospitalization Kidney disease Liver disease
Migraine headaches Miscarriage Multiple sclerosis Natural labor Neuromuscular issues
Osteoarthritis Trauma/injury OTHER
What are your (or are the patient's) current work habits? Choose all that apply.
No change in work habits since condition began Cannot not work due to presenting condition None reported
Permanently fully disabled Permanently partially disabled
0 to 20 hours per week 20 to 40 hours per week 40 to 50 hours per week
50 to 60 hours per week 60 to 70 hours per week Over 70 hours per week
Full-time Part-time Homemaker Retired Student Unemployed
Mostly sitting Mostly standing Mostly walking Light labor Moderate labor Heavy labor Sedentary
Computer Repetitive Telephone Difficult Enjoyable Relaxed Stressful
Past, Family and Social History (3):
How would you describe your (or the patient's) personal social habits? Choose all that apply.
No change in social habits since injury Does not smoke, drink alcohol or take recreational drugs
A social drinker A light drinker A moderate drinker
A heavy drinker An alcoholic A recovering alcoholic
Current every day smoker Current some day smoker Ex-smoker
Heavy tobacco smoker Light tobacco smoker Never smoked tobacco
Smoker, current status unknown Unknown if ever smoked
Does not drink caffeine Drinks 1 cup of caffeine in the morning Drinks 2 to 4 cups of caffeine per day
Drinks 5 or more cups of caffeine per day
Does not use recreational drugs Light use of recreational drugs Moderate use of recreational drugs
Heavy use of recreational drugs Is drug addicted Is a recovering drug addict
How would you describe your (or the patient's) present exercise habits? Choose all that apply.
No changes in exercise habits since condition began
Daily None Every other day Few times a week Once a week Almost nothing
Aerobic Stretching Strength Baseball Basketball Blading
Boating Climbing Cycling Football Golf Handball
Hang gliding Hiking Ice skating Mountain climbing Ping-Pong Racquetball
Running Skiing Skydiving Snowboarding Soccer Surfing
Tennis Volleyball Walking Waterskiing Weight training
Weight training with a personal trainer Pilates Spinning Step Yoga
Zumba
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.
No changes in diet or nutrition since condition began
Controlled Out-of-control Restricted Unrestricted 1 to 2 meals a day
2 to 3 meals a day More than 3 meals a day Reports eating too little Reports eating too much Binges
Purges Balanced High protein Low carbohydrate Low-fat
Low-cholesterol No red meat Atkins Diabetic Gluten free
Ideal Protein Jenny Craig Kosher Macrobiotic Paleo
Raw food South Beach Vegan Vegetarian Weight Watchers
Zone Does not take daily supplements Takes daily supplements OTHER
Past, Family and Social History (4):
Alcohol: Daily Weekly Occasionaly Never
Diet Food Products: Daily Weekly Occasionaly Never
OTC Stimulants: Daily Weekly Occasionaly Never
Homemade Food: Daily Weekly Occasionaly Never
Soft Drinks: Daily Weekly Occasionaly Never
Water: Daily Weekly Occasionaly Never
Patient Social
Caffeine: Daily Weekly Occasionaly Never
Drugs: Daily Weekly Occasionaly Never
Exercise: Daily Weekly Occasionaly Never
Processed: Daily Weekly Occasionaly Never
Tobacco: Daily Weekly Occasionaly Never
Who referred you to our office:
Where did you hear about us? Newspaper Sign Yellow Pages Mailing Community Event Other
Have you been adjusted by a chiropractor before? Yes No
Has any member of your family ever seen a wellness chiropractor? Yes No
Chiropractic Experience:
If yes, Why?
Doctor's Name: Approximate Date of Visit
People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever ismalfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of caredesired so that we may be guided by your wishes whenever possible.
I want the Doctor to select the type of care appropriate for my condition
Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic Care
Goals for Your Care
Last Physical Exam:
Phys City:
Health Conditions:
Previous Chiro Care: Yes No
Chance Pregnant: Yes No
Medications:
Supplements:
Personal Health History
Primary Phys:
Phys State:
Date:
Planning: Yes No
Phys Phone #:
Phys Zip:
Condition(s) treated:
Chiropractic is the largest natural healing profession in the world? Yes No
The nervous system controls all bodily functions and systems? Yes No
Were you aware that...
Doctor's of Chiropractic work with the nervous system? Yes No
Signature Date:
